A hospital based study of prevalence of gestational diabetes mellitus in an urban population of India

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1 European Review for Medical and Pharmacological Sciences A hospital based study of prevalence of gestational diabetes mellitus in an urban population of India M.V. JALI*, B.R. DESAI**, S. GOWDA #, S. KAMBAR***, S.M. JALI 2011; 15: *Diabetes Centre, Medical Director & CEO, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, K.L.E. University, Belgaum (India); **Department of Obstetrics & Gynecology, Jawaharlal Nehru Medical College, Belgaum (India); ***Department of Community Medicine, Jawaharlal Nehru Medical College, Belgaum (India); # Department of Biomedical Science, Division of Biochemistry, College of Medicine, King Faisal University, Al-Hasa (Kingdom of Saudi Arabia); Department of Pediatrics, Jawaharlal Nehru Medical College, Belgaum (India) Abstract. Objective: A cross-sectional institutional-based study was undertaken to know the prevalence of Gestational Diabetes Mellitus (GDM) among Indian pregnant women. Subjects and Methods: 325 pregnant women were screened for evidence of diabetes who were previously not known to be diabetic. They underwent 75 g, 2 hour, oral glucose tolerance test (OGTT). Chi-square test was done for statistically association of variables in GDM. Results and Conclusions: The results of this study indicate that bad obstetrics history, obese patient on high calorie diet especially non vegetarian diet with less physical activity are highly prone to develop GDM. Key Words: Gestational diabetes mellitus, Body mass index, Physical activity. Introduction Pregnancy induces insulin resistance and diabetogenic stress due to placental hormones which in turn, cause abnormal glucose intolerance. Gestational Diabetes Mellitus (GDM) quite often encountered in outpatient care. The prevalence of GDM in India has varied from 3.8% to 21% depending upon the diagnostic methods used 1. Based on demographic projections made by United Nations Population Division (UNPD) for the year 2025, WHO issued estimates of adults with diabetes in all countries of the world and reported that there will be more women with diabetes than men and it is anticipated a considerable raise in the burden of gestational diabetes mellitus (GDM) especially in less affluent countries 2. Maternal hyperglycemia is considered as a risk factor for foetal morbidity. A pregnant woman who is unable to have sufficient insulin secretion to overcome the insulin resistance that occurs during normal pregnancy is susceptible to develop the gestational diabetes 3. Materials and Methods A cross-sectional institutional-based study was undertaken to know the prevalence of Gestational Diabetes Mellitus among pregnant women attending the Diabetes Centre, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka State of India during the period between May 2008 and April pregnant women were screened for evidence of diabetes mellitus who were previously not known to be diabetic. These women voluntarily consented for the glucose challenge tests at the Hospital s Diabetes Centre. Women already having diabetes prior to conception were excluded. These women underwent 75 g, 2 hour, oral glucose tolerance test (OGTT) and diagnosis was established according to WHO criteria i.e., GDM 2 hours 140 mg/dl 4. The recent data on the prevalence of GDM in our country was 16.55% by WHO criteria of 2 hr plasma glucose 140 mg/dl 5. Statistical Analysis Chi-square test was done using SPSS 14.0 version (SPSS, Inc., Chicago, IL, USA). Value of p < 0.05 was considered statistically significant Corresponding Author: M.V. Jali, MD; drmvjali@gmail.com

2 A hospital based study of prevalence of gestational diabetes mellitus in an urban population of India Table I. Prevalence of GDM according to age of the subjects. Age group years Total (pregnant women) Total cases (GDM) % Total % χ 2 = 6.462; DF = 4; p = Results Overall 52 (16%) pregnant women found to have GDM. Age specific prevalence was found to be higher in years (22.3%) compared to other age groups. However, the results were statistically not significant (p = 0.167) as shown in Table I. Our study showed the prevalence of GDM was more amongst subjects with a family history of diabetes compared to subjects without a family history of diabetes. Further, GDM subjects with both parents diabetic (50%) exhibited greater risk compared to single parent diabetic (26.9%). This shows stronger family history would make pregnant women prone for abnormal glucose tolerance. However results were statistically not significant (p = 0.172) as shown in Table II. The prevalence of GDM was more among subjects with previous bad obstetric history (BOH) (24.4%) which could be due, to frequent insulin resistance and diabetogenic stress caused by placental hormones. The results were statistically significant (p = 0.000) as shown in Table II. We also found that non-vegetarian pregnant women (61.5%) are more susceptible to develop abnormal glucose tolerance. It may be due to high fat, high calorie and low fiber diet. Table IV show the results that were statistically significant (p = 0.000). Moreover, our study showed the prevalence of GDM was highest (46.3%) among women who were obese be- fore conception, and followed by 19.8% women who were overweight before conception compared to women with ideal BMI (5.8%) as shown in Table V. Thus, this study indicate that physical activity plays a vital role in maternal carbohydrate metabolism. Prevalence of GDM was more among sedentary women (57.7%) compared to women with irregular physical activity (26.9%) and regular physical activity (15.4%). The results were statistically significant (p = 0.001) as shown in Table VI. Discussion Gestational diabetes mellitus forms the most common medical complication of pregnancy. Women with GDM are at a higher risk for numerous maternal health complications, and their infants are at a higher risk for death and morbidity. The prevalence of GDM is high in Indian population 6. The factors that have been postulated to influence the risk of GDM among the mothers include obesity, positive family history of diabetes in first-degree relatives, treatment for infertility, polyhydramnios, recurrent urinary tract infection (UTI), recurrent moniliasis, history of still birth, delivery of a large infant (>4 kg), unexplained neonatal death, prematurity, pre-eclampsia in multi- Table II. Prevalence of GDM according to family history of diabetes. Group Single parent diabetic Both parent diabetic No family history Total GDM 14 (26.9%) 26 (50%) 12 (23.1%) 52 Non GDM 80 (29.3%) 101 (37.0%) 92 (33.7%) 273 Total χ 2 = 3.515; DF = 2; p =

3 M.V. Jali, B.R. Desai, S. Gowda, S. Kambar, S.M. Jali Table III. Prevalence of GDM according to previous obstetric history. Obstetric history Total No. Cases Good (5.9%) Bad (24.4%) Total χ 2 = ; DF = 1; p = para, diabetes in previous pregnancy, and advancing maternal age 7. This work provides baseline information about the determinants of GDM, which could potentially help to incorporate early intervention measures. In this investigation, we found an overall 52 (16%) pregnant women to have GDM. Age specific prevalence was higher in years (22.3%) as compared to other age groups. Moreover, our study showed the prevalence of GDM was more amongst subjects with a family history of diabetes compared to subjects without a family history of diabetes. Further, GDM subjects having both parents diabetic (50%) exhibited greater risk compared to single parent being diabetic (26.9%). Similar prospective case control study undertaken in China in 2005, reported that a family history of diabetes greatly increased the incidence of GDM 8. Similar results have been reported by other studies researches 9,10. But, the results were statistically significant in the prevalence of GDM among subjects with previous bad obstetric history (BOH) (24.4%). This was also observed in one of the population-based longitudinal study. It concluded that mild pre-eclampsia and chronic hypertension, with superimposed pre-eclampsia, occurred more frequently in women with GDM 11,12. Table IV. Prevalence of GDM according to diet pattern. Group Vegetarian Non-vegetarian Total GDM 20 (38.5%) 32 (65.5%) 52 Non GDM 182 (66.7%) 91 (33.3%) 273 Total χ 2 = ; DF = 1; p = Table V. Prevalence of GDM according to body mass index (BMI). BMI (kg/m 2 ) Number GDM cases % (Normal weight) (Over weight) (Obesity) Total χ 2 = ; DF = 2; p = Table VI. Prevalence of GDM according to physical activity. Group Regular exercise Irregular exercise NIL Total GDM 8 (15.4%) 14 (26.9%) 30 (57.7%) 52 Non GDM 108 (39.5%) 72 (26.4%) 93 (34.1%) 273 Total χ 2 = ; DF = 2; p =

4 A hospital based study of prevalence of gestational diabetes mellitus in an urban population of India Diet composition may be a modifiable predictor of risk for abnormal glucose tolerance during pregnancy. Previous studies suggest that diets high in total fat, saturated fat, red and processed meats, and with high glycogenic load increase the risk of developing gestational diabetes mellitus (GDM), while polyunsaturated fats, carbohydrates and fibers are protective 13. In our study, we found that non-vegetarian pregnant women (61.5%) were more susceptible to develop abnormal glucose tolerance. It may be due to high fat, high calorie and low fiber diet. The results were statistically significant. Recently, some of the studies have examined diet quality during pregnancy as a potentially modifiable contributor to GDM risk In particular, Saldana et al 18 showed that higher intake of fat and lower intake of carbohydrates may be associated with increased risk of GDM and impaired glucose tolerance (IGT). High fiber intake, which has been consistently linked to decreased risk of type 2 diabetes mellitus (DM) among non-pregnant adults 20-22, was related to lower risk of GDM in two studies 23,24. Studies have been done to find the association between body mass index (BMI), exercise, and the prevalence of GDM. The results of this investigation revealed that women with BMI of 33 or less had similar rates of GDM that were not associated with whether or not they had exercised during their pregnancies. In contrast, women who were with a BMI >33 and who exercised were much more likely to have lower rates of GDM compared with overweight women who did not exercise. This observation may reflect an important underlying relation between adiposity and GDM and the magnitude of the potential impact of exercise given the relation between these two variables. In obese individuals, aerobic exercise decreases the hyperinsulinemia of obesity and decreases fasting plasma glucose levels. With the improvement of insulin sensitivity, there is an increase in the suppression of hepatic glucose production, resulting in an increase in insulin-stimulated glucose uptake. Thus, overweight obese women who exercise while pregnant may have a decreased likelihood of developing GDM during their pregnancy 25. Even in our study, we found the prevalence of GDM was highest (46.3%) among women who were obese before conception, and followed by 19.8% women who were overweight before conception compared to women with ideal BMI (5.8%). This was statistically significant. Hence, exercise has been advocated as an alternative therapeutic intervention not only in the management of the gestational diabetes but also in the prevention of diabetes 26. Further, exercise during pregnancy specifically has resulted in a reduction in the number of women whose GDM must be managed by insulin therapy 27. Despite initial concerns about possible deleterious effects of exercise in pregnant women, physical activity has been shown to be safe during pregnancy 28. The studies have revealed physical activity plays a vital role in maternal carbohydrate metabolism. The prevalence of GDM was more among sedentary women (57.7%) compared to women with irregular (26.9%) or regular physical activity (15.4%). In one of the cohort study that included over 1,800 pregnant women, who had been engaged in vigorous physical activity before pregnancy and light-to-moderate or vigorous activity during pregnancy experienced a reduced risk for developing gestational diabetes mellitus and abnormal glucose tolerance. Women were particularly benefited much better if they were physically active prior to and during pregnancy. Walking appeared somewhat protective while sedentary lifestyle somewhat harmful. These results can be extended to pregnancy and appreciate the protective effect of physical activity against the development of diabetes, which has previously been demonstrated among adult men and non-pregnant women The increased trend of GDM in India has become a potential public health problem. Timely action should be taken to screen all pregnant women for glucose tolerance, and achieve euglycemia in them and ensure a healthy diet, regular physical activity and follow-up at antenatal clinic, would definitely reduce the further rise of GDM and poor outcome of pregnancy. Acknowledgements We thank Mr. M. D. Mallapur, Biostatistician of Jawaharlal Nehru Medical College in Belgaum for his technical support, the co-operation of staff of KLES Diabetes Centre and the Medical Record Division of the KLES Dr. Prabhakar Kore Hospital is gratefully acknowledged. Thanks to Professor P S Shankar, Emeritus Professor of Medicine, J N Medical College, Belgaum & M. R. Medical College, Gulbarga, India for his valuable suggestions during the preparation of this manuscript. 1309

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